Hindawi Publishing Corporation Gastroenterology Research and Practice Volume 2016, Article ID 6802810, 7 pages http://dx.doi.org/10.1155/2016/6802810
Review Article Optimal Bowel Preparation for Video Capsule Endoscopy Hyun Joo Song,1 Jeong Seop Moon,2 and Ki-Nam Shim3 1
Department of Internal Medicine, Jeju National University School of Medicine, Jeju, Republic of Korea Department of Internal Medicine, Inje University College of Medicine, Seoul, Republic of Korea 3 Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Republic of Korea 2
Correspondence should be addressed to Jeong Seop Moon; [email protected] Received 30 June 2015; Accepted 22 October 2015 Academic Editor: Anastasios Koulaouzidis Copyright © 2016 Hyun Joo Song et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. During video capsule endoscopy (VCE), several factors, such as air bubbles, food material in the small bowel, and delayed gastric and small bowel transit time, influence diagnostic yield, small bowel visualization quality, and cecal completion rate. Therefore, bowel preparation before VCE is as essential as bowel preparation before colonoscopy. To date, there have been many comparative studies, consensus, and guidelines regarding different kinds of bowel cleansing agents in bowel preparation for small bowel VCE. Presently, polyethylene glycol- (PEG-) based regimens are given primary recommendation. Sodium picosulphate-based regimens are secondarily recommended, as their cleansing efficacy is less than that of PEG-based regimens. Sodium phosphate as well as complementary simethicone and prokinetics use are considered. In this paper, we reviewed previous studies regarding bowel preparation for small bowel VCE and suggested optimal bowel preparation of VCE.
1. Introduction Video capsule endoscopy (VCE) is useful in investigating small bowel as well as esophagus, stomach, and colon. Bowel preparation for small bowel VCE is recommended to improve small bowel visualization quality (SBVQ), diagnostic yield (DY), and cecal completion rate (CR). Particularly in the distal small bowel, DY of VCE can be limited due to reduced SBVQ-associated with residual material or dark colored bile. According to a 2009 meta-analysis of 12 studies [1], purgative bowel cleansing prior to VCE improves the SBVQ and increases the DY but does not alter the VCE CR. However, the gastric transit time (GTT) and small bowel transit time (SBTT) of VCE were not affected by purgatives. We performed online search for VCE bowel preparationrelated clinical studies, comparative research, randomized controlled trials (RCTs), meta-analyses, and guidelines published from January 2002 to June 2015. Literature review was conducted using Key MeSH terms of “capsule endoscopy” and “bowel preparation.” We also reviewed bowel preparation guidelines for VCE of small bowel based on 2009 European Society of Gastrointestinal Endoscopy (ESGE)
guidelines [2], 2013 ESGE guidelines [3], and 2013 Korean guidelines [4] by the Korean Gut Image Study Group, part of the Korean Society of Gastrointestinal Endoscopy. The level of scientific evidence for recommendation was based on study design; for example, the evidence of randomized trial was considered high, observation study was low, and any other type of evidence was very low. The validity of the recommendation was divided into categories of “strong” or “weak” (Table 1) [5]. In this paper, we introduced previous studies on bowel preparation for VCE and suggested optimal preparation methods.
2. Purgatives 2.1. Polyethylene Glycol. Polyethylene glycol- (PEG-) based regimens are first-line recommendation (Grade A) [3]. The majority of the evidence of bowel preparation prior to small bowel VCE is PEG-based regimens. The 2009 ESGE guidelines recommended purgative bowel preparations in order to enhance small bowel DY by VCE without affecting the CR (category of evidence, 2a; grade of recommendation, B) [2].
2
Gastroenterology Research and Practice Table 1: Quality of evidence and strength of a recommendation. Quality of evidence
High quality Moderate quality Low quality Very low quality Strong
Further research is very unlikely to change our confidence in the estimate of effect. Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Any estimate of effect is very uncertain. Strength of a recommendation Most or all individuals will be best served by the recommended course of action. Not all individuals will be best served by the recommended course of action. There is a need to consider more carefully than usual individual patient’s circumstances, preferences, and values.
Weak
Table 2: Studies comparing SBVQ, DY, and CR between PEG solution versus clear liquid or fasting of small bowel VCE. Author (year, area) Viazis et al. [6] (2004, Greece) van Tuyl et al. [7] (2007, Netherlands) Endo et al. [8]∗ (2008, Japan) Wi et al. [9] (2009, Korea) Rey et al. [10] (2009, France) Park et al. [11] (2011, Korea) Ito et al. [12]∗ (2012, Japan) Rosa et al. [13] (2013, Portugal) Dai et al. [14] (2005, Switzerland) Ben-Soussan et al. [15] (2005, France)
Design
Number
Prospective RCT
80
Prospective RCT
60
Prospective RCT
59
Prospective RCT
99
Prospective RCT
116
Prospective RCT
43
Prospective RCT
42
Prospective RCT
60
Prospective blinded nonrandomized trial
61
Retrospective study
42
PEG versus clear liquid diet or fasting SBVQ 90% versus 60% 𝑝 = 0.004 72% versus 25% 𝑝 = 0.001 N/A 𝑝 < 0.01 56% versus 43% 𝑝 = NS 83.1% versus 38.6% 𝑝 < 0.05 2.43 versus 2.26 𝑝 = 0.045 4.4 ± 0.8 versus 2.7 ± 1.0 𝑝 = 0.00004 83.3% versus 65% 𝑝 = 0.0417 3.04 versus 2.41 𝑝 < 0.01 57.6% versus 62.5% 𝑝 = NS
DY 65% versus 30% 𝑝 = 0.003 30% versus 27% 𝑝 = 0.86 78.6% versus 71.6% 𝑝 = NS 50% versus 39% 𝑝 = 0.111
88.9% versus 65.6% 𝑝 = 0.038 71% versus 75% 𝑝 = 0.924
N/A
N/A
65% versus 56.6% 𝑝 = NS
75% versus 73% 𝑝 = 0.869 85.0% versus 81.8% 𝑝 = 0.89 100% versus 88.9% 𝑝 = 0.312 97% versus 76% 𝑝 < 0.01 92.3% versus 100.0% 𝑝 = NS
N/A 60% versus 44.4% 𝑝 = 0.587 N/A 46.2% versus 50.0% 𝑝 = NS
CR 80% versus 65% 𝑝 = 0.21 N/A
PEG: polyethylene glycol, VCE: video capsule endoscopy, RCT: randomized-controlled trial, SBVQ: small bowel visualization quality, DY: diagnostic yield, CR: completion rate, N/A: not applicable, and NS: no significant. ∗ PEG 500 mL.
According to the Korean Gut Image Study Group guidelines [4], bowel preparation with PEG solution enhances DY and SBVQ, without effect on cecal CR (strong recommendation, moderate quality evidence). Table 2 shows many studies regarding bowel preparation with comparison of PEG versus clear liquid or fasting for small bowel VCE, including prospective randomized controlled trials [6–13], a prospective blinded nonrandomized trial [14], and a retrospective study [15]. Most studies were performed by comparing SBVQ, DY, and cecal CR between 2 L PEG solution and clear diet or fasting groups. Four-liter PEG solution was used in a few studies [10, 14]. In addition, ingestion of a small amount of PEG (500 mL) beginning 30 minutes after swallowing the capsule significantly improves SBVQ and cecal CR, although DY was not affected [8]. Another study regarding a small amount (500 mL) of PEG
solution over 2 hours, beginning 30 minutes after swallowing the capsule, showed increased SBVQ without any difference in cecal CR [12]. Since PEG is completely transparent, a view through PEG was considered better than a view through natural intestinal fluid. However, negative result regarding SBVQ with 2 L PEG was reported in one retrospective study [15]. Two-liter PEG solution bowel preparation is similar to that of 4 liters of PEG in DY, SBVQ, and CR of VCE (weak recommendation, moderate quality evidence). Two studies by Kantianis et al. [16] and Park et al. [11] indicated no significant difference between 2 L and 4 L PEG in regard to small bowel cleansing and CR. Therefore, 2 L PEG should be recommended as preparation for VCE, administered on the day prior to the procedure, as the most commonly used preparation method [17].
Gastroenterology Research and Practice
3
Table 3: Definitions of optimal bowel preparation of VCE among studies with PEG. Author (year, area)
Design
Viazis et al. [6] (2004, Greece)
Prospective RCT
80
Prospective RCT
60
Prospective RCT
59
Wi et al. [9] (2009, Korea)
Prospective RCT
99
Rey et al. [10] (2009, France)
Prospective RCT
116
Park et al. [11] (2011, Korea)
Prospective RCT
43
Ito et al. [12]∗ (2012, Japan)
Prospective RCT
42
Rosa et al. [13] (2013, Portugal)
Prospective RCT
60
van Tuyl et al. [7] (2007, Netherlands) Endo et al. [8]∗ (2008, Japan)
Dai et al. [14] Prospective blinded (2005, Switzerland) nonrandomized trial Ben-Soussan et al. [15] Retrospective study (2005, France)
Number Quality of bowel preparation
61 42
Clean: if
Review Article Optimal Bowel Preparation for Video Capsule Endoscopy Hyun Joo Song,1 Jeong Seop Moon,2 and Ki-Nam Shim3 1
Department of Internal Medicine, Jeju National University School of Medicine, Jeju, Republic of Korea Department of Internal Medicine, Inje University College of Medicine, Seoul, Republic of Korea 3 Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Republic of Korea 2
Correspondence should be addressed to Jeong Seop Moon; [email protected] Received 30 June 2015; Accepted 22 October 2015 Academic Editor: Anastasios Koulaouzidis Copyright © 2016 Hyun Joo Song et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. During video capsule endoscopy (VCE), several factors, such as air bubbles, food material in the small bowel, and delayed gastric and small bowel transit time, influence diagnostic yield, small bowel visualization quality, and cecal completion rate. Therefore, bowel preparation before VCE is as essential as bowel preparation before colonoscopy. To date, there have been many comparative studies, consensus, and guidelines regarding different kinds of bowel cleansing agents in bowel preparation for small bowel VCE. Presently, polyethylene glycol- (PEG-) based regimens are given primary recommendation. Sodium picosulphate-based regimens are secondarily recommended, as their cleansing efficacy is less than that of PEG-based regimens. Sodium phosphate as well as complementary simethicone and prokinetics use are considered. In this paper, we reviewed previous studies regarding bowel preparation for small bowel VCE and suggested optimal bowel preparation of VCE.
1. Introduction Video capsule endoscopy (VCE) is useful in investigating small bowel as well as esophagus, stomach, and colon. Bowel preparation for small bowel VCE is recommended to improve small bowel visualization quality (SBVQ), diagnostic yield (DY), and cecal completion rate (CR). Particularly in the distal small bowel, DY of VCE can be limited due to reduced SBVQ-associated with residual material or dark colored bile. According to a 2009 meta-analysis of 12 studies [1], purgative bowel cleansing prior to VCE improves the SBVQ and increases the DY but does not alter the VCE CR. However, the gastric transit time (GTT) and small bowel transit time (SBTT) of VCE were not affected by purgatives. We performed online search for VCE bowel preparationrelated clinical studies, comparative research, randomized controlled trials (RCTs), meta-analyses, and guidelines published from January 2002 to June 2015. Literature review was conducted using Key MeSH terms of “capsule endoscopy” and “bowel preparation.” We also reviewed bowel preparation guidelines for VCE of small bowel based on 2009 European Society of Gastrointestinal Endoscopy (ESGE)
guidelines [2], 2013 ESGE guidelines [3], and 2013 Korean guidelines [4] by the Korean Gut Image Study Group, part of the Korean Society of Gastrointestinal Endoscopy. The level of scientific evidence for recommendation was based on study design; for example, the evidence of randomized trial was considered high, observation study was low, and any other type of evidence was very low. The validity of the recommendation was divided into categories of “strong” or “weak” (Table 1) [5]. In this paper, we introduced previous studies on bowel preparation for VCE and suggested optimal preparation methods.
2. Purgatives 2.1. Polyethylene Glycol. Polyethylene glycol- (PEG-) based regimens are first-line recommendation (Grade A) [3]. The majority of the evidence of bowel preparation prior to small bowel VCE is PEG-based regimens. The 2009 ESGE guidelines recommended purgative bowel preparations in order to enhance small bowel DY by VCE without affecting the CR (category of evidence, 2a; grade of recommendation, B) [2].
2
Gastroenterology Research and Practice Table 1: Quality of evidence and strength of a recommendation. Quality of evidence
High quality Moderate quality Low quality Very low quality Strong
Further research is very unlikely to change our confidence in the estimate of effect. Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Any estimate of effect is very uncertain. Strength of a recommendation Most or all individuals will be best served by the recommended course of action. Not all individuals will be best served by the recommended course of action. There is a need to consider more carefully than usual individual patient’s circumstances, preferences, and values.
Weak
Table 2: Studies comparing SBVQ, DY, and CR between PEG solution versus clear liquid or fasting of small bowel VCE. Author (year, area) Viazis et al. [6] (2004, Greece) van Tuyl et al. [7] (2007, Netherlands) Endo et al. [8]∗ (2008, Japan) Wi et al. [9] (2009, Korea) Rey et al. [10] (2009, France) Park et al. [11] (2011, Korea) Ito et al. [12]∗ (2012, Japan) Rosa et al. [13] (2013, Portugal) Dai et al. [14] (2005, Switzerland) Ben-Soussan et al. [15] (2005, France)
Design
Number
Prospective RCT
80
Prospective RCT
60
Prospective RCT
59
Prospective RCT
99
Prospective RCT
116
Prospective RCT
43
Prospective RCT
42
Prospective RCT
60
Prospective blinded nonrandomized trial
61
Retrospective study
42
PEG versus clear liquid diet or fasting SBVQ 90% versus 60% 𝑝 = 0.004 72% versus 25% 𝑝 = 0.001 N/A 𝑝 < 0.01 56% versus 43% 𝑝 = NS 83.1% versus 38.6% 𝑝 < 0.05 2.43 versus 2.26 𝑝 = 0.045 4.4 ± 0.8 versus 2.7 ± 1.0 𝑝 = 0.00004 83.3% versus 65% 𝑝 = 0.0417 3.04 versus 2.41 𝑝 < 0.01 57.6% versus 62.5% 𝑝 = NS
DY 65% versus 30% 𝑝 = 0.003 30% versus 27% 𝑝 = 0.86 78.6% versus 71.6% 𝑝 = NS 50% versus 39% 𝑝 = 0.111
88.9% versus 65.6% 𝑝 = 0.038 71% versus 75% 𝑝 = 0.924
N/A
N/A
65% versus 56.6% 𝑝 = NS
75% versus 73% 𝑝 = 0.869 85.0% versus 81.8% 𝑝 = 0.89 100% versus 88.9% 𝑝 = 0.312 97% versus 76% 𝑝 < 0.01 92.3% versus 100.0% 𝑝 = NS
N/A 60% versus 44.4% 𝑝 = 0.587 N/A 46.2% versus 50.0% 𝑝 = NS
CR 80% versus 65% 𝑝 = 0.21 N/A
PEG: polyethylene glycol, VCE: video capsule endoscopy, RCT: randomized-controlled trial, SBVQ: small bowel visualization quality, DY: diagnostic yield, CR: completion rate, N/A: not applicable, and NS: no significant. ∗ PEG 500 mL.
According to the Korean Gut Image Study Group guidelines [4], bowel preparation with PEG solution enhances DY and SBVQ, without effect on cecal CR (strong recommendation, moderate quality evidence). Table 2 shows many studies regarding bowel preparation with comparison of PEG versus clear liquid or fasting for small bowel VCE, including prospective randomized controlled trials [6–13], a prospective blinded nonrandomized trial [14], and a retrospective study [15]. Most studies were performed by comparing SBVQ, DY, and cecal CR between 2 L PEG solution and clear diet or fasting groups. Four-liter PEG solution was used in a few studies [10, 14]. In addition, ingestion of a small amount of PEG (500 mL) beginning 30 minutes after swallowing the capsule significantly improves SBVQ and cecal CR, although DY was not affected [8]. Another study regarding a small amount (500 mL) of PEG
solution over 2 hours, beginning 30 minutes after swallowing the capsule, showed increased SBVQ without any difference in cecal CR [12]. Since PEG is completely transparent, a view through PEG was considered better than a view through natural intestinal fluid. However, negative result regarding SBVQ with 2 L PEG was reported in one retrospective study [15]. Two-liter PEG solution bowel preparation is similar to that of 4 liters of PEG in DY, SBVQ, and CR of VCE (weak recommendation, moderate quality evidence). Two studies by Kantianis et al. [16] and Park et al. [11] indicated no significant difference between 2 L and 4 L PEG in regard to small bowel cleansing and CR. Therefore, 2 L PEG should be recommended as preparation for VCE, administered on the day prior to the procedure, as the most commonly used preparation method [17].
Gastroenterology Research and Practice
3
Table 3: Definitions of optimal bowel preparation of VCE among studies with PEG. Author (year, area)
Design
Viazis et al. [6] (2004, Greece)
Prospective RCT
80
Prospective RCT
60
Prospective RCT
59
Wi et al. [9] (2009, Korea)
Prospective RCT
99
Rey et al. [10] (2009, France)
Prospective RCT
116
Park et al. [11] (2011, Korea)
Prospective RCT
43
Ito et al. [12]∗ (2012, Japan)
Prospective RCT
42
Rosa et al. [13] (2013, Portugal)
Prospective RCT
60
van Tuyl et al. [7] (2007, Netherlands) Endo et al. [8]∗ (2008, Japan)
Dai et al. [14] Prospective blinded (2005, Switzerland) nonrandomized trial Ben-Soussan et al. [15] Retrospective study (2005, France)
Number Quality of bowel preparation
61 42
Clean: if
